MEDICATION ERRORS: Nothing to sniff at

August 2004 
Volume 34  Number 8
Pages 14 - 14
  PDF Version Available!

© 2004 Lippincott Williams & Wilkins, Inc. Volume 34(8)             August 2004             p 14 Nothing to sniff at [MEDICATION ERRORS: INHALANT CAPSULES]


A nurse retrieved what she thought was an inhalant ampule of ammonia spirits for a patient who'd fainted. When she crushed the cotton-wrapped ampule and placed it under the patient's nostrils, she didn't smell the usual strong odor and the patient didn't awaken. Thinking the inhalant was inactive, she crushed another ampule with the same poor results. She then realized that the ampule contained amyl nitrite, a rapid-acting vasodilator. The pharmacy had accidentally stocked the wrong drug.

Although you should always read the label of any medication before you administer it, the print label on a crushable ampule may be difficult to read through the protective covering. Some facilities use ...

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